The burden of diabetes is increasing in epidemic proportions. Blood glucose abnormalities are common among hospitalized patients and are associated with poor clinical and economic outcomes. Despite evidence of effective strategies for inpatient glycemic control and the existence of clinical practice guidelines, inpatient glucose management remains suboptimal, and patients at risk or with unrecognized diabetes are frequently overlooked. The suboptimal recognition and management of diabetes in the hospital appears to be due to various factors beyond knowledge deficits among health care providers. Multiple barriers prevent optimal delivery of care. What predisposes to the persistence of these barriers is not clearly understood and represents a major gap in knowledge that this application will address. Aim 1 will test the hypothesis that the use of qualitative research methods, including clinical practice observations and interviews of health care providers, will identify wha promotes the presence of gaps in diabetes care and will provide cues on how barriers can be corrected. Utilizing the knowledge derived from this innovative approach, coupled with recommendations derived by existing clinical practice guidelines, a novel electronic medical records-driven clinical decision support tool will be developed. Upon detection of a deficiency in the recognition and/or management of a dysglycemic episode, this tool will alert the medical staff and instruct them how to correct it. In Aim 2 Dr. Pichardo-Lowden will create this novel tool and test its effectiveness in a pilot study. Based on its effect size, a large clinical trial will e appropriately powered. Aim 3 will consist on a clinical trial that will test the hypothesis that usng such electronic medical record clinical decision support tool across intensive and non-intensive care units will reduce the incidence of hyperglycemia and hypoglycemia; increase detection of patients with or at risk for diabetes; improve documentation of diagnosis and glycemic status, improve inpatient diabetes care practice among providers; and reduce hospital's length of stay and readmission rates. This K23 Award will allow Dr. Pichardo-Lowden to acquire competency in qualitative research methods, integration of quality improvement strategies in health care, and public health sciences competency which will be essential to become an independent investigator in health care delivery in the area of diabetes. Dr. Pichardo-Lowden's long term career goal is to study the long-term impact of the implementation of this clinical decision support tool in collaboration with other institutions by conducting a multicenter study and assess the impact of care in the following domains of clinical practice in a larger population: 1. Early detection of diabetes; 2. Inpatient care of diabetes and dysglycemia; 3. Continuity of patient care; 4. Modification of clinical practice behaviors among providers' users of the tool; 5. Economic impact; and 6. Inpatient morbidity and mortality. For this she plans to pursue extramural funding through an R01 or equivalent mechanism.